Public Works Maintenance Request

This form is intended for residents to report infrastructure issues within the municipality, such as potholes, broken sidewalks, malfunctioning streetlights, or other public works-related concerns. Submissions will be reviewed by the public works department for follow-up and resolution.

Resident Information

• Full Name: {fullName}
• Phone Number: {phone}
• Email Address: {email}
• Address: {address}

Issue Location

• Street Address: {issueAddress}
• Nearest Cross Street: {crossStreet}
• Zip Code: {zipCode}

Description of Issue

Issue Type: {issueType}

Details:

{issueDescription}

{#photos}

Photos Provided: Yes

Attached image(s) will be included with this request.

{%photo}

{/photos}

{^photos}

Photo Provided: No

No images were included with this report.

{/photos}

Severity and Public Safety

Is this issue a safety hazard?: {isSafetyHazard}

{#$ safetyNotes}

Additional Safety Information:

{safetyNotes}

{/}

Schedule Availability for Inspection

Preferred Contact Method: {contactMethod}

Preferred Time for Inspection/Visit: {preferredTime}

Previous Reports

{#wasReportedBefore}

This issue has been previously reported.

{/wasReportedBefore}

{^wasReportedBefore}

This is the first report of this issue.

{/wasReportedBefore}

Additional Notes

{notes}

Date of Submission: {submissionDate}

Thank you for taking the time to help maintain and improve our community infrastructure. Your submission will be reviewed by the appropriate municipal staff.